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92 OCEAN AVE - BUILDING INSPECTION L& per -AoHs APPROVE0 6Y T4iE _. WSPEXTDR ,PSWIR TP A.PERMIT B,EWG GRANTED = CITY OF SALEM '3 ��))1 No UJ �" Date Is Property Located In Location of the Historic District? Yes_No Building q/ 7 06 ef/a"e - SYfL/'� Is Property Located in the Conservation Area? Yes_No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool, Repair/Replace, Other: l���Cz�re �T Ly�,ri06<vs PLEASE FILL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specifications: Owner's Name M I C tt A C1 D , D o N A L D +- MAR Y Address & Phone l 5 /A V o 7i 5' =7 f F,7 Architect's Name Address & Phone Mechanics Name Address & Phone QzM7��' z 7 Z What is the purpose of building? fn JyoTr Material of building? H ie% If a dwelling,for how many families? 3 Will building conform to law? Asbestos? Na Estimated cost :�/ery-Ga CitylLicense e N A State License Home Improvement L4 Lie. t /6/!;7'F'r ignature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE MAIL PERMIT TO: No. 0O� APPLICATION FOR �Q PERMIT TO LOCATION PERMIT GRANTED WiM z AP OVED INSPECTOA OF BUIL INGS } Fw 1 CITY OR SALEM, MASSACHUSBTTS (• • PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3R9 FLOOR SALEM. MASSACNUSW"a 01970 STAMLEY J. USOVICE, JR. TELEPHONE: 978.745-959S EXT. 380 MAYOR FAX: 978-740.9444 Salem Buidlna Depamwnl Debris ftodhM In accordance with the provisions of MGL C40 S 549 a condition of your Building Permit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL Chapter M. S 150 A. The debris will be disposed of in: (Location of Facility) Signature of Applicant Date The Commonwealth of Massachusetts Department oflndustrial Accidents O,flee of inttesdgadons 600 Washington Sued Boston,MA 02111 www massgo1VA% Workers'Compensation Insurance Affidavit: Bnilders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name on/l�lvid:tal)t Address: City/Statea4: x 17 Phone# An you so employer?Cheek theappropride bore Type ofproject(required): 1.❑ I am a employer with 4. [2 1 am a genad contractor and I employees(thn and/or parl-time).* have hired ibe sub untrechm 6: ❑New constroctioa 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. [] Remodeling ship and have no employees These sub-contracom have 8. ❑ Demolition work,for me in any capacity, workgt'comp. iosurance. g, ❑ Building addition [No workers'comp.insurance . 5. ElWe are a torporalmn arid,its' rcgnired}- ofilceis have 'tnrer�ersed then 10 repairs or additions 3.❑ I am a bomeownet.doing all work right ofexemptiou per MGL- 11.0 Plumbing repairs or additions myself [NoworlrW.comp a 152,41NXandQhsvc`ho 12 Roofrepaaf insoraooe requiroij t. eIDP1oYe� [No�vorlters';, 13.❑ Other corV.insurance regnved) „ ;Amy applicant that checks box Nl tout also 58 oft tlie.eatim below ahowioa ffieir.,prasl 'cenpeaaoon mosey inib"undow Homeownaa wLo atbndt ffiit affidavit iodieeriva guy ire doing ell sat god Pons lilue`oatdde nntart subs*a sew affadavit iidiedinH such tContack n dM cheek this box'imat dtoched ire additional AM sbown to norm bfdwm coffftot rs and*A*wwkew wn*L poHT inAmnation; lam ate impioyerdaf isprovWina workers'eompmadoe basmaaee forssy cNOkytea Below L dYepol/ry and job sire Info na.don. Insurance Company Name: Policy#or Self-au.Lie, #: Expiration Date: Job Site Address: City/Statrtlip: Attach a copy of the workere compensation policy declaration page(ebowing the Polley number and explratfon daft)6 Fatibme to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or onayear imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA far insurance coverage verification. 1 As herby cen*under the paha and penabla ofperlury thef the inforatadoa provided above is true and correct Signature: Darr Phone#: O,dleial use mOL Do sot wrbe br this area,to bs eoapieted by eby orMwa oh'leieL City or Tows: PermMoense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#• Information and Instructions -, ,eompeosation far their emph�}+txe. - .. Massachusetts General i ads chapter 152 requires all employers10 pmvrl4<�vurk4s contract of hire, Pursuant to this statute, an empla� Yes is defined as"...every.P�in the service Qf anotber under any express or implied,oral or wr►llm association,corporation fir other legal entity,or any two or more An employer is defined as"an b&'r duA partnership,ditcl es of a deceased amPIUM.er the of the foregoing enpo-in a joint enterprise,and iociadm8 ' bed, However the receiver or vista of an indmdaal,parmersmp.association or other hgrtpl resides emPbYiog r th y of the''' owner of a dwelling house having not more than three Winlents and who resides theteID,or the occupant dwelling bouse of another wbo employs persons to do maintenance,construction y repair deem employment be deemed Stichd to be a a en employer-" mp boas" or on the groins or btrr7ding appurtenant themeto stall not because of such employment " e shall withhold the lumusee or Ikeoslo agency MGL chapter 152,125C(6)abur states that"every state or local gag renewal of a Becase or permit to operate a business or to construct bsildings Is the roman ea"for any applicant who hs not produced acceptable evidence of compliance with the inaraace coverage required Additionally,MGL chapter 15Z¢2SC(7)states"Neither the con000mreahh ism any of its political suhdivisiom shall a of public wort until acceptable evidence of comPliana with the insurance into contract for the performan " . enter enY th"oarpratxmB awhoritY. requirements of this chapter have been presented Applicants lion affidavit completely,by checking the boxes that apply>D your situation and,if Please Sq,out the workers'comQ�sa es and bone ntnabcr(s)along with their catigtate(s)of necessary,supply sub-cetrtracbr(s)uame(sb address( ) . . P ees other than the insurance. Limited liability Companies(LLB or Limited Liabiht'y Partnerships U Y)with no employ members or partuels, are not required to carry.worker°' compensation msursace' If an LLC or LLY does have employees,a policy is required Be advised dial this affidavit may be submitted to the Department of bidttsbw Accidents kit ffidavit confnmation of insurance coverage. Also be sure to dp and date the aifl not the Departrneshm d be returned to the city or town that the application for the permit or license is bang requested. industrial'Accidema Sb4uld you have any questions regarding die law or if you are regoired to obtain a workers' call the Department at die number ljsted below. Self insured companies should eater(heir campen6ation policy:lice on the self-insurancense u lima City or Town Offielals Please be sure that the affidavit is convict"an printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant' Please be sure to fill in the punW iccm number which will be used as a reference number. In addition,an applicant that mast submit ill in to P e eons in any given yam't�only submit one affidavit indicating current policy information(if necessary).?nd,under"Job Site Address"the applicant sbould write"all lmtions in . (city or town}"A wPY of the affidavit t>nthaabcm officially stamped.or_mwb d bythhe city or town may be pwvrded to the , applicant as proof that a valid affilavit is on Me for!future permits on c�insea. A new afl3davit tuhstbe filled out each year Where a home owner or citizen obtaining a license or permit not related;to any busioesa or fat vcamr" (ie a dog license Of penmt 10 bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would lrlre to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a ca1L The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of industrial Accidents Office of investtgattona 600 Washington Street Boston,MA 02111 TeL #617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia A L T- Y T" FusT- Information and Instructions compensation for their emPloyees. Massachusetts General Laws chapter 152 requires all emPloyeq.10 P��r.��' contract of hire, pursuant tothis statute, an emplayn is defined as"...every Denson in the savior 4f another under any express or implied.oral or written." An employer ma defined as an individual.pannashiP,asgocmation,corporation nir other legal entity.or any two or mere in a joint enterer. ad including the legal mimes of deceased em01OW, tba of the foregoing engaged, n or other legal entity,empkryiug employees. Howeve{the receiver or UUMe of an individual,pa�� do and who resides therein,or the Occupant of."'. owner of a dwelling house having not more than three coo on each dwelling house dwelling house of another who employs persons to do maintenance'construction or repair work „ or on the groins or bw7ding appurtenant tbereb shall not because of such employment be deemed to be an employer. MGL chapter 152.$25C(6)also states that"every state or local licensing agency shag withhold the bmsnce or renewal of a license or permit to operate a buslnm or to construct buildin6s L the eornmoewealth for any produced acceptable evidence of compliance with the insurance coverage required•" Applicant who horn not p state"Neither the commonwcahh nor airy of ib political subdivisions shall Anitioually,MGL chapter 15Z 125C(� ofpublio work until acceptable evidence of compfianee wih the insurance amen into any contract€or the pace requirements of this chapter have been presentedIn the contracting anlLorie Applicants _ affidavit completely,by checking the boxes that apply to your situation and,if Please tryout the wotke n'compensation es and Phone number(s)along with then certificates)of necessary,supply sorb-coaes)name(s),address( ) with no employees other than the ,.Me& Limited Liabilriy ComPasiea(i-LO or Limited Liability Partnerships(I.LP) members or paAaas,We not ralaired tu carry worms,compensation boraum If an LLC or LLP does have tted to die Department Of bduVW employees,a policy is required. Be advised that this affidavit maysure s d date the affl ne affidavit should Accidents for tenon of inanrance coverage. Also be, be retumod to the city or towns tbat the application for the permit of license is being requested,not the Dcparfament of Should you have any questions regard rig the law or if you are requited to obtain a workers' Industrial'Accidema pstod below. Self-insured companies should eater their compensation policy;plow can the Department at the number self-iosuanceliaose tritimbet on the a line. City or Town Of ciab Please be sure that the affidavit is complete and printed legibly The Department has provided a apace at the bottom of the affidavit far you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the peridacewc number which will be used as a reference number. In addition,an aPPhoam that mast submit nomltiple permiu icense applications in any liven year,need only submit one affidavit indicating current policl,information(if necessary)an,under"Job Site Address"the applicant should write"all locadons hi (City or ' or marked by the city or town may be provided to the town}"A copy of the af9dsvit that hn been officraDl!stampal_. _ applicant as proof list a valid affidavit is on file for fhtare permits or licenses Anew affidsivit>mefbe f�out each year.Where a home owner or citizen is obtaining a licence or permit not related.to any business or om»»rercial venture (Le.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidsvif. The Ofce of Investigations would hire to thank you in advance for your cooperation ad should you have any questions, please do not hesitate to give us a call: The Department's address,telephone an fax numbs The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia The Commonwealth ojMassachusetts Department ojlndustrid Accidents O,Q?ce of ltntesd'gadons 600 Washington Stred Boston,MA 02111 www massgotddid Workers'Compensation Insurance Affidavit: BWMeiWContractols/Electiicians/Plnmbers ADDticant Information Please Print Legibly Name (flnss!Orization/lodivldaal)7 Address: City/State/Zip: " Phone# Are you as em4►royer?Ch1 et eke appropriate bor. Type of project(required): 1.❑ I am a employer with 4 [2 1 am a general contractor and I 6: []New construction employed(OA and/or part tone) Lave hired the sob coattaeton 2.❑ I am a sole proprietor or partner- listed on dw attached shut t 7. ❑ Remodeling ship and have no employees new sub-contractor have S. ❑ Demolition working for me in any capacity. workm,comp. iusWMM 9. Q Building addition [No workers'camp,insurance 5. Wear" a corporatmn and iis' regairod oi8cas have "ace lsed their 10.0 Electrical repairs or additions 3.(] I am a bomeowner.doing all work right ofeaemPtign per MGL' 11.0 Plumbing repairs or additions myself[No workeW.comp: a 152,pl(4X solid wt have-no 12,0 Roof repaid iasuranae requireQ t �PIoY [ o worked' „ cotop.itnrvana ralnved J ' ME] Other ;Any ePP mer chuka bw:,Ml vns peso fill out*section below showing lbeit.,waet W ampma> s Policy IDSom.tim, . Honvoweea wbo what inn affidavit izesee 4 m doing aD work end they hji¢0'd•aWe mall. 1 : 1l1M wbmR a new affidavit i such lCoebacwpo dW Aeck this boi`iooat etoeehed r edditioaai sbeer showing the none 469suAooedaGae we heir workers'caq,Policy inflOrmed= lam atr'eeaployerthet is providiWg xwrkers'eonipnuarloe br=mxire jor my+st pluytEa Below ir thepolky and rob site lrrlornrotiort. insurance Company Name: Policy#or Self-ins.Lic #: Expiration Date: Job Site Addrms: , City/SraW74: Attach a copy of the workers'compensation policy declaration Page(showing the number and P�9 expiration date). Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a fine up to$11500.00 and/or onayear imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby ceno under do pains end peeables ojpajuey that the iejonrralloe provided above it true and correct Sismatme: Datr Phone#: O fIelal use only. Do eat write bs this any to be compkted by ciy atmm efflekL City or Tows: PermWl.lcense# Issuing Authority(circle one): 1.Board of Health Z.Building Department 3.CHyfrows Clerk 4.Electrical inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: